Substance Use & Misuse, 50:523–531, 2015 C 2015 Informa Healthcare USA, Inc. Copyright  ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2015.977709

BRIEF REPORT

What Was Bad Is Now Good, and What Was Good Is Now Bad: Changes in Our Views and Images of Addiction and Addicts Manuella Adrian Department of Economics, University of Guelph, Guelph, Ontario, Canada

• How many users? • How many alcoholics? • How many addicts? • What did they use3 and in what ways? • What did these substances do temporarily as well as permanently? • What were the medical, legal, social or economic consequences4 of using, and for whom? • What were the bio-psycho-social mechanisms, or major theories that explained addiction? • What were the major types of therapies or prevention interventions, and how effective were they, both temporarily as well as more permanently? • What were the major political issues surrounding addiction? • Who were the major players – stakeholders- in the field whether government or international agencies? • What were the major modes of administration5 of different drugs? Etc., Etc.

In 1977, an elderly family member being treated for advanced cancer asked me to get him some marijuana. A conservative abstemious person, he was participating in an early stage clinical trial of an experimental treatment. Totally wretched with persistent nausea, unable to eat or swallow, he wanted marijuana because he had read in the newspaper that this was good for what ailed him. I was profoundly shocked. I was then head of the statistical research section at the Alcoholism and Drug Addiction Research Foundation of Ontario (ARF), then one of the world’s foremost addiction research organizations1 . I thought I knew a lot about addiction2 . Addiction was the term applied to the compulsive use of substances or the compulsive carrying out of selected behaviors (such as gambling, sex, porn, computers, exercise, shopping, gaming, etc.) that interfere with the ordinary conduct of normal everyday life. Physiological tolerance developed as the body became habituated and dependent on the substances (behaviors), and ever larger doses were needed to experience the same effect. Many addicted drug-deprived users developed unpleasant withdrawal symptoms, depending upon the drug they were using and the site of their use, that they sought to escape by continuing drug use. From a public policy viewpoint it was important to know:

I had published extensively in many of these areas6 and felt I had a reasonable grasp of what was involved. In reality, it turned out that I knew nothing. The main focus in the burgeoning and institutionalized addiction “field” was, and continues to be, the negative effects of substance use or misuse; the main effort has been to stop, or even prevent, addiction. Selected and targeted, visibly targetable users and misusers, addicts and

1 ARF (founded 1949) predates the Rutgers Center of Alcohol Studies (1950), the Finnish Foundation for Alcohol Studies (1950), as well as NIDA and NIAAA (1974). 2 The terms “Addiction” and “Addicts” is taken as a short-hand for substance users or misusers, whatever the substance (alcohol, drugs, etc.), as well as other addictive-type behaviors. 3 Alcohol, wine, beer, spirits, narcotics, prescription drugs, tranquilizers, sedatives, hypnotics, narcotics, cannabis, cocaine, heroin, acid, LSD, mushrooms, Ecstasy (MDMA), club drugs, etc. 4 Morbidity and mortality from alcoholism, alcohol dependence, drug dependence, liver cirrhosis, esophageal varices, enlarged heart, drug dependence, poisonings, traffic accidents, work accidents; crime, police charges, incarcerations, drunk driving, trafficking, using; family and work problems, reduced labor productivity, costs of treatment and law enforcement, social costs to society, government revenue from alcohol and tobacco taxes, etc. 5 Smoking, sniffing, injecting, ingesting, transdermal patches, etc. 6 Adrian M, Jull P, Williams B (Series Published 1977 to 1989) Statistics on Alcohol and Drug Use in Canada and Other Countries. Toronto: Addiction Research Foundation. Address correspondence to Manuella Adrian, Adjunct Research Associate, Department of Economics, University of Guelph, Guelph, Ontario, Canada. E-mail: [email protected]

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alcoholics were people who had problems, and whose addiction had become a problem for their families, friends, colleagues, employers. In short, addiction was BAD and the problem of addiction had to be FIXED! Most people working in the addiction field and who are trying to alleviate the problem of addiction are scientists, therapists, researchers, policy makers, who are all stakeholders in “the problem.” This being the age of science, they take a scientific, rational, objective, evidencebased technocratic approach, looking at the facts from the outside in order to effectuate an intervention whose effects could be evaluated in terms of its ability to achieve a visible measurable effect: patients were cured (however “cure” was defined); social ills (however “ills” were defined) were prevented; a law/regulation/therapy/theory was formulated, tested, revised, adopted, implemented, evaluated, re-formulated, etc. In the field of addiction, like in many other fields of inquiry, researchers and practitioners share a subjectspecific common professional world view. This world view is so deeply embedded within the fabric of our society and thinking patterns, that even professionals are no longer aware of its influence on their thinking and understanding of the world. Thus, they may accept the view that addiction is a problem that has to be fixed by changing . . . something. Usually the addict. They work within the confines of certain accepted theoretical models in the field, and work at improving these models and making them easier to put into practice in the most cost effective way. The implications and consequences of the commodification of a constructed social problem continue to be inadequately perceived, considered, and explored. Information on new and improved ways of dealing with the problem of addiction—which has, historically, been related to as a sin-moralization, then a crime-criminalization, and more recently a chronic disease-medicalization—is communicated through publications, conferences, media stories, and other mechanisms that act as a marker of professional success. The more people adopt such ideas, methods, or treatments, the more famous and influential the therapist or researcher becomes, and the greater their power and financial rewards, including academic tenure, grants, patents, patients, clinics, hospitals, royalties, awards such as the Order of Canada 2012 (Harold Kalant, Alcohol researcher), the Presidential Medal of Freedom 2008 (Anthony Fauci, AIDS researcher), or the Nobel Prize 1992 (Gary Becker, Rational addiction model). These are considerable inducements to follow the classic approach for dealing with addiction as a problem to be alleviated. Putting effort into new untested ideas that challenge the status quo requires not only an innovator who has imagination and who is an independent thinker, but one with courage, and who is an activist or has a radical bent of mind. The innovator may find him/herself to be a voice crying in the wilderness, someone with little influence and marginalized. New, interesting, provocative findings may be looked at but may remain unseen. Study results may be considered so different and counterintuitive that they are

ignored or disbelieved. Their import remains misunderstood not only by society but by the researcher him/herself who puts the work aside and never looks at it again. Most researchers, unlike physicist Albert Einstein, do not have a colleague to point out the brilliant meaning of our own results when their import eludes us7 . Orthodoxy in the addiction field held that drug use was BAD, that the pathologized users were misguided or helpless against their addiction. Certainly, the problems of addiction were the main focus of modern research and a range of interventions and any possibilities that there were positive aspects to substance use were not given much emphasis. A few studies, done on injection drug use among street people or in needle exchange clinics, reported that some addicts said they were using illegal substances to selfmedicate because they were sick and feeling lousy. This was interpreted by researchers as meaning that addicts perceived their withdrawal symptoms as an “illness” that could be cured by the substances they were using—an aspect of the “hair of the dog” cure for hangover. However, many researchers felt that this was just an “excuse to justify illegal drug use.” Researchers who thought this might actually reflect that some addicts really believed and experienced drug use as effective self-medication, generally argued that addicts would be better served if whatever selfmedicated8 “sickness” (withdrawal, depression, anxiety, etc.) was treated through regular treatment channels, using conventional medical or counseling therapeutic intervention techniques, and the use of legal prescribable pharmaceutical products of established dosages and standard potency. I think at this point it would be useful for the field of addiction to look more seriously at how drug users/addicts, who represent a heterogeneous and not a homog-eneous population of people with differential individual and social resources, think about their lives, what they consider to be their lived reality, what they like about it, what they dislike about it, what they would like to change as they adapt and function in various daily roles in a range of contexts, situations, social and systemic networks, communities, and institutions. Each of us has an understanding, a belief system of what our lives are about: shopping, cooking, driving, house maintenance, working, digging a ditch, installing pipe, sitting in an office, going to meetings, negotiating contracts, paying, evaluating, being angry, delighted, playing with our children, talking with neighbors, texting with family, Skyping with colleagues, smoking a little weed, getting drunk, sleeping on the beach, begging in 7

Shortly after the publication of Einstein’s general theory of relativity in 1915, the Russian mathematician Alexander Friedmann was surprised to discover that Einstein had failed to notice a remarkable prediction made by his equations: that the universe is expanding. This prediction was later confirmed by observations made by Edwin Hubble in the 1920s. cited in http://oaks.nvg.org/sa5ra17.html retrieved October 11, 2014 8 Self-medication may include the use of illegal substances, or the use of legal substances used in unapproved or illegal ways.

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front of a store, voting, waiting in the emergency department, getting to the bomb shelter, donning a gas mask, being sick, watching our loved ones die, experiencing grief, walking, eating, sleeping, having sex, smoking a cigarette, giving birth, preparing meals, taking Xanax, looking for food, sleeping in an emergency shelter for the homeless, living in a tent in a refugee camp, going to school, harvesting watermelons, looking for a job, working in a metal fabricating factory, shooting up, watching the Roomba vacuuming the condo floor, surfing the web, hacking a bank account, having a drink, playing Bingo at the church bazaar, going to Vegas, taking a plane . . .. . ..

• How can we reconcile all these different experiences? • Which of these behaviors are characteristic of addicts. . . as living, dynamic, complex people and not as static, unidimensional entities and images? • Which of these behaviors, many of them common everyday occurrences, take a particular meaning for the addict as a person, or have a different significance in the life of an “addict” than they would in the life of a non-addict person or of both of them in different times, places and circumstances? • Which of these behaviors are important, necessary, random, irrelevant? • What is there to like? • What is there to dislike? • What could or should be changed? And by whom? • How are we to best meet the needs of addicts whose experiences, needs, expectations, wishes, preferences, judgments and decisions are rarely, if ever, taken into account, except by those who stand to profit from dealing with them? Governments, partly funded by taxes9 on tobacco or alcohol, struggle with how much to raise taxes before the higher price reduces the amount sold to the point that government revenue declines. Legal or illegal manufacturers, distributors and retailers of substances do occasionally listen to substance users mainly to make consumption easier. The pharmaceutical industry develops new drugs that are touted as being more effective and less costly, with fewer side effects, or to be easier to swallow (gel cap vs. tablet), or with “improved flavor” (viz. orange flavored Bayer Chewable low dose Aspirin10 ). New substances are introduced with different characteristics or new pharmaco-active ingredients (analgesic with Acetominophen [Tyleno] vs. Acetysalycilic acid [Aspirin]), or increased potency, even if the new higher dose exceeds the amount that can be metabolized by the body in one day, with the excess excreted! Better channels of distribution are set up for an improved shopping experience; retail therapy is an option. Purchasing alcohol has moved from the dismal and forbidding government liquor store to the 9

In Canada in the 1980s, alcohol- and tobacco-related taxes accounted for a combined 6% of all government revenue (see footnote 6, above). 10 http://www.target.com/p/bayer-chewable-aspirin-orange-flavor/-/A15111332?ref=tgt adv XSG10001&AFID=google pla df&LNM= 15111332&CPNG=Health±Beauty&kpid=15111332&LID=17pgs& ci src=17588969&ci sku=15111332&kpid=15111332&gclid=CJf5 g6nfmMECFabm7AodhSUANg retrieved October 6, 2014,

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grocery store’s fine wine section. The pot buyer has gone from seeking out the back-street dealer to buying from the legal purveyor of medicinal or recreational marijuana. The prevarification of Prohibition’s medicinal alcohol has been replaced by the commodified “medical marijuana” as sources of profit for individuals and systems. All these efforts are intended to increase sales and profits. But do they make life better for the addict? For his family and his community? In the long run? Are these the only improvements that can be made in the life of the person who is a user of addictive substances or who exhibits addictive behaviors? For a long time, Stanley Einstein has emphasized the power differential between THEM and US. THEY are the drug users, the alkies and the druggies, the sickos, the street people, the criminal, the patient, the outsider who doesn’t belong or whose role in society is at best marginal. THEY are someone who has to be managed by the formal apparatus of the state and be persuaded into a conventional life or coerced into conformity and made to behave as WE think THEY should.

• WE, of course, are the powers that be. WE set the conventional social standards of the day, define morality, determine what is health as well as illness and disease, what people should do and how, where they may live and where they had better not be if they know what is good for them if they don’t want the full majesty of the law to fall upon them. This precludes the homeless from living on the street lest they be arrested or expelled if found within city boundaries. WE maintain OUR power, OUR status, OUR reputation through OUR controlling role over THEIR lives. Any change to the status quo would diminish US and lead to social chaos (essentially any differentiation from the current condition). WE OURSELVES become entrenched stake-holders for the continuance of the current situation. There have been vigorous and repeated calls to reduce (and maybe eliminate) the social distance and power differential between THEM and US. Although this may have increased OUR awareness of this issue, it is still a call to arms that depends on US leading the way. In a sense, it is an intellectualized call for Noblesse Oblige where the princely powers (US) condescend to act to allow some improvement in the lot of social inferiors (THEM). In the current system of addiction treatment there is little, if any, role for THEM to voice what THEY would like to have happen in THEIR lives notwithstanding the increased role of recovery-associated interventions and people-in-recovery as change agents. It is true that there may be challenges for people whose thinking and behaviors are unconventional, illegal, dysfunctional in terms of daily living or who have difficulties in expressing themselves or articulating THEIR wants and needs, in a way that expresses what is best for THEMSELVES, in ways that WE can understand without it doing violence to what THEY mean. Yet, other subordinate groups have managed to get their message across in a way that is both eloquent and persuasive.

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Minorities11 that made progress in improving their social status until they were able to exercise a degree of self-determination and meet their real needs did so through a gradual process. Initially, improvements in the quality of life and social status of minorities stem from the benevolent intervention by selected members of the Majority, or dominant group, who champion the rights and freedoms of minorities (e.g., Northern abolitionists who helped slaves escape the South and reach the relative safety of the American Free Northern States, and Canada); eventually the American Civil War (1861-1865) was fought over this issue. However, equality of opportunity was not achieved until members of the minority group themselves became increasingly involved in the fight for their own rights and the achieving of self-empowerment (Civil Rights March, Washington, August 28, 1963). Indeed, access to the highest levels of status and power (viz. election of Hawaii-born African-American Barack H. Obama to the Presidency of the United States of America) was not itself achieved until the members of the minority group formed the numeric majority among those active in seeking full rights and equality. Major achievements in reaching higher goals of selfsufficiency and empowerment require the taking of an active role by the members of the minority group. Most important is their role in defining the agenda in terms of how they want themselves and the issues to be perceived by others in society, and what they want to be able to do within the context of the mainstream society in which their subgroup is embedded. This includes affecting everpresent institutionalized barriers in the relevant systems. A similar path from disempowered “other-ness” to full (or fuller) participation in mainstream society is seen among other minorities, including Native Americans who achieved Nation status for their reserves (Canada) or reservations (USA) which opened the gate to lucrative economic development projects through the opening of Native-owned casinos on their land. Gays are gaining normal civil status for their spouses and children: the first legal same-sex marriage in modern times was performed in Canada in 2001 (registered in 2003, made retroactive to 2001)12 , after the Metro Credit Union in Toronto was the first commercial enterprise to offer full same-sex family benefits to its employees in the 1980s. The disabled are provided legally-required accommodations in public spaces, at work or in home environments; programs are available in many large communities for the “normalization” of developmentally handicapped or disabled persons where they are accepted as they are—with their disabilities—in the course of daily life. Essentially the ways to reduce the distance between THEM and US is another aspect of “normalization,” 11 The term “Minorities” is used here in the sense that within mainstream population there are subpopulations that are or were discriminated against on various grounds, such as religion, gender, social status, caste, language, accent, nationality, disability, ethnicity, race, age, region, etc. 12 http://en.wikipedia.org/wiki/Timeline of same-sex marriage#Ancient times

where those who are from un-empowered or minority groups, be they women, African Americans, Native Americans, the disabled, gay people, and possibly, someday, the addict, can achieve the same legal rights as the mainstream and become accepted and considered by themselves and by others and by the mainstream, to be entitled to exercise these rights. Now is the time for needed fuller participation of those who are most closely involved in the everyday lived reality of “addiction.” This will allow a better understanding of addiction, in order to meet the needs and expectations of the many kinds of addicts as persons so that they may be more fully integrated into mainstream society. Addicts, as individuals as well as influencing stakeholders, need to share their experiences so that those social structures and institutions with which they interact can be aware of and meet their needs. Interventions need to be responsive to the needs of addicts in terms of what (if any) interventions are needed and how they are to be applied, for how long and where, so as to be consistent with what addicts themselves want. One may surmise that addicts may want to have easier access to formerly illegal now legalized drugs without running afoul of the law, getting a criminal record, or facing mandatory incarceration–Such wants and needs are not wholly unachievable. In the past heroin use was seen as a medical problem that was to be dealt through medical means. Since the 1920s British physicians have been able to prescribe heroin for the treatment of opiate dependence13 to registered addicts whose number was low (less than 100 per year, no more than 1000 by the 1970s). In the 1980s, the number of heroin addicts started to grow (peaking at 350,000 in the 1990s)14 and now hovers around 300, 00015 . Methadone has become the treatment of choice, with pharmaceutical heroin restricted to the very few who do not respond to methadone. Drug courts in the USA, started in Miami Dade County in 198916 , now number some 2800. They divert drug users from incarceration to treatment that provides intensive treatment and other services to help addicts get and stay clean and sober17 ; they have been found to be effective in reducing recidivism18 . 13

Stimson GV, Metrebian N (2003) Prescribing Heroin: What Is The Evidence? http://www.jrf.org.uk/publications/prescribing-heroinwhat-evidence retrieved October 6, 2014. 14 Eardley N (2014) Heroin abuse—does the UK still have a problem? BBC News. May 2, 2014 http://www.bbc.com/news/uk-27235470 retrieved October 6, 2014. 15 King’s College London(2012). Treatment Programmes For Chronic Heroin Addicts. http://www.kcl.ac.uk/ioppn/about/difference/RIOTT. aspx retrieved October 6, 2014. 16 National Association Of Drug Court Professionals (Undated) History Justice Professionals Pursue A Vision http://www.nadcp.org/learn/ what-are-drug-courts/drug-court-history 17 National Association Of Drug Court Professionals (Undated) What Are Drug Courts? The Most Effective Justice Strategy Addressing The Drug-Addicted And Mentally Ill. . . http://www.nadcp.org/learn/ what-are-drug-courts 18 Mitchell O, Wilson DB, Eggers A, MacKenzie DL (2012) Assessing the effectiveness of drug courts on recidivism: A meta-analytic review of traditional and non-traditional drug courts. Journal of Criminal

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Addicts may want their drugs to be safe and free of dangerous adulterants. Certainly this is what happened after the repeal of Prohibition. Illegal alcohol sold during Prohibition contained poor quality ingredients due to too rapid cheap manufacturing. Some illegal alcohol intercepted by police was deliberately adulterated to discourage users, although this had scant effect. “As many as 10,000 people died from drinking denatured alcohol before Prohibition ended”19 Post-Prohibition legal alcohol now consisted of ethyl alcohol without toxic methyl alcohol or other substances. In the fight against marijuana the toxic weed killer paraquat sprayed on marijuana fields to control supply was at one point considered as a possible deterrent to users20 . Drug users may prefer that the type of drug which they choose to use, the method of use or the site of use should be safe and not put their lives in danger. Harm reduction interventions include supervised injection sites (clean shooting galleries) and needle exchange programs (NEP). Clean shooting galleries are intended to reduce the public nuisance aspect of those who inject in public spaces (parks, toilets, bus stops, and train stations) and provide a hygienic environment for illicit drug users where both the risks of disease from injection drug use and overdose can be reduced or controlled. Although there was a reduction in public nuisance an unexpected result is that overdoses increased as users were emboldened to try more exotic mixtures of drugs than usual as they knew help was available if they had a bad reaction. In terms of cost effectiveness results were mixed21 . NEPs provide clean needles to injection drug users to prevent blood-borne infections; however, the optimum distribution of NEPs is costly to achieve especially when counseling is also provided, and this may account for inconsistent results. The Zero Tolerance and War on Drugs approaches, which may be considered to be flawed conceptualizations in terms of achievable results and which need to be “retired”, may also have contributed to lesser interest in NEP22 . That the possession of syringes remains illegal in some jurisdictions brings police in conflict with NEP users and this too prevents achieving the full health and social benefits of NEP23

Justice 40 (2012) 60–71 cited in http://www.courtinnovation.org/sites/ default/files/documents/Assessing Effectiveness.pdf retrieved October 6, 2014. 19 Blum D (2010-02-19). The Chemist’s War: The Little-told Story of How the U.S. Government Poisoned Alcohol During Prohibition with Deadly Consequences. Slate. Retrieved 2013-11-07. Cited in http://en.wikipedia.org/wiki/Prohibition in the United States. Retrieved October 6, 2014 20 Time (1988) Drugs: War on Pot And Paraquat, Monday, July 25. http://content.time.com/time/magazine/article/0,9171,967951,00.html retrieved October 6, 2014. 21 http://en.wikipedia.org/wiki/Supervised injection site#Impact on public nuisance retrieved October 6, 2014. 22 Strathdee SA, Vlahov D (2001). The effectiveness of needle exchange programs: A review of the science and policy. AIDScience Vol. 1, No. 16, December 2001, http://aidscience.org/Articles/aidscience013.asp retrieved October 6, 2014. 23 http://en.wikipedia.org/wiki/Needle exchange programme. Retrieved October 6, 2014.

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Addicts may want to be able to use drugs without medical complications—something akin to the fictional drug SOMA first introduced by author Aldous Huxley in his book Brave New World. Finally, like all consumers addicts may seek novelty and want a constant stream of new drugs and new drug experiences—this may well account for the user who grabs whatever is available and uses them all at once to experience what that feels like. Such behavior is not only the characteristic of some “heavy users” of today, but was also the preferred mode of drug consumption of Voltaire, the 18th century French writer and philosopher who was said to grab and gobble up like candy whatever pills were available in the house, including “pills for female troubles” used by his mistress the mathematician Emilie, Marquise of Chatelet. Certainly, the manufacturers of illegal drugs are constantly cooking up new synthetic drugs or changing the mix of ingredients in substances as does the pharmacy industry who, in addition to enabling levels of health and treatment options, also function as disease mongers24 as they medicalize a range of human behaviors. It is likely that purveyors of newly legalized drugs will continue this, emphasizing vintage and “terroir”25 not just for wine26 but for marijuana27 as well. One problem with giving full participation to the voice of the addict may be concerns some people have with historical developments in regard to certain substances. Over the course of a century, alcohol went from being a normal ordinary consumable product occasionally vilified by a vocal, abstemious, often religious, minority, to a banned product (Prohibition). Eventually alcohol was brought back into the market as a regulated product with limited or controlled distribution. Former bootleggers and rumrunners became respectable business people, heads of multimillion dollar alcoholic beverage manufacturing and distribution enterprises (such as the Bronfmans 24

Disease mongering is a relatively new perjorative term first used in 1992 by health writer Lynn Payer (Payer, Lynn (1992). Diseasemongers : how doctors, drug companies, and insurers are making you feel sick. New York: J. Wiley) to describe the process for: (1) expanding the diagnostic boundaries of illnesses into a stakeholder-bound, flawed, consensualized disease conceptualization, (2) promoting public awareness of the new constructed and professionally transmitted “disease”, or condition, (3) and creating and expanding the markets for those who sell and deliver treatments, (i.e. pharmaceutical companies, physicians, and other professional or consumer organizations.). Assessing the overall effect of the ever-increasing process of medicalization of human behaviors is complex owing to the inherently social, political and religious nature of the definitions of what constitutes a disease, health, and the even new concept of quality-of-life, among other influences, as well as what aspects of the human condition should be managed according to a medical model or with other treatment traditions. 25 Terroir is a French term used by oenologists to describe the wine characteristics due to soil composition, drainage, hilly vs. flat terrain, hours of sunshine or days of rain, average temperature during growth season, etc. Terroir is considered to account for flavor, aroma, potency due to agricultural methods or geo-physical environment where vines and, by extension, marijuana are grown. 26 Viz. Oscar-winning movie Sideways (2004), 27 Viz. Long-running (2004-2011) winner of numerous awards (BAFTA, Emmy, Golden Globes, and many others) HBO TV series Entourage

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of Canada, owners of Seagrams Distilleries), and political powerhouses (such as American Joe Kennedy, Ambassador to England and father of President John F. Kennedy, Attorney General Robert Kennedy, and of long serving Senator Ted Kennedy). We may soon see the legitimized pot multi-millionaire not only in Neal Stephenson’s 2011 Science Fiction novel Reamde. Our view of marijuana has also been going through changes and is approaching normalization. What was considered to be and related to as being bad a decade ago may now be considered the norm. In the 1960s’ marijuana use began to spread beyond the minority ethnic enclaves to which it had hitherto been confined when white middle class college students began to use it. Along with the hippie movement and the counter-culture, marijuana use spread throughout society leading to a conservative anti-marijuana backlash by the 1970s28 . Mainstream news media reported a link between cannabis use and violence, de-motivation—a consensualized, medicalized a-motivational syndrome—and dire warnings of the many harm drugs do to youth. Some warnings against drugs and their use were exaggerations or based on misinterpretation of facts. Yes, there were cases of psychosis linked to cannabis29 use, but these occurred among people whose daily use was at extremely high doses in such places as India where hashish use resulted in cannabis levels many times greater than those achieved by average American recreational marijuana users. Indeed, college students who experimented with marijuana were now graduating and entering the work world where their continuing recreational marijuana use did not result in the nefarious consequences they had been told to expect New cautionary tales emphasized marijuana’s role as an all-powerful “gateway drug” leading in a linear, unidimensional trajectory to “hard drug” use by a disempowered THEM. Certainly many users of other addictive illegal substances start with using marijuana, but the truth is that for most marijuana users, marijuana did not act as a gateway drug. Nor does beer lead to wine and then on to the consumption of more potent alcoholic spirits, or cigarettes on to chewing tobacco, cigars, and to pipe smoking. Indeed most casual recreational marijuana users did not go on to become the socially constructed “junkies” mainlining heroin or cokeheads cooking up free-base crack cocaine. Most users of marijuana, in their own experience and in the experience of those around them, did not progress to the use of “harder drugs.” The framing device shifted its focus on marijuana use leading to entry into the criminal world. Because marijuana was illegal, to buy it you had to have contact with a criminal. One of the major problems with marijuana, and indeed with most illegal drugs, is that users need (or needed) to have contact with criminal elements in order 28 http://www.pbs.org/wgbh/pages/frontline/shows/dope/etc/cron.html retrieved October 6, 2014 29 Cannabis ITHC) is one of the main psychoactive ingredients in both marijuana and hashish, but its concentration is much greater in hashish (40%) than in marijuana (10%) http://news.softpedia.com/news/What039-s-The-Difference-Between-Hashish-and-Marijuana-51954.shtml retrieved October 4, 2014)

to access their drug of choice, even when that “criminal” is no more than the self-styled uber-cool high-schooler who, surprisingly, doesn’t necessarily drop out to join the Mafia or a biker gang. He may simply be a budding entrepreneur who loves risk-taking, goes to business school and, like Doug Ford30 —former youthful drug dealer in an affluent neighborhood—becomes Toronto city councilor, or his brother Rob Ford31 infamous for his belligerent public drunkenness and coke use while mayor of Toronto (Canada). The person who smoked marijuana while in College may well become a casual recreational user who uses marijuana to relax and have a time-out from the stresses of everyday life as a serial entrepreneur and founder of multiple major billion-dollar firms, like Steve Jobs32 , founder of Apple and Pixar. Despite draconian antidrug laws, with mandatory sentencing or “3 strikes and you’re out” policies, marijuana use has continued to climb until lifetime marijuana use today is reported by 44% of Canadians aged 15+ (2005)33 , and 42% of Americans aged 18+ (2002-2003)34 . It is clear that classic warnings and cautionary tales have seriously lost their credibility. Between 1973 and 2014, 23 American states have variously decriminalized or legalized the use of marijuana, whether for medical or recreational purposes35 . Already states that have legalized recreational marijuana for persons aged 21 and over are attempting to limit use by those under age 21 by using cautionary warnings in public health messages with catchy slogans “Does Marijuana really cause schizophrenia in teenagers? Smoke and find out.” and “Subjects needed. Must be a teenager. Must smoke weed. Must have 8 IQ points to spare.”36 The ironic tone has not prevented criticism from Colorado’s legal pot industry and mockery from the young unimpressed by scare tactics. To quote baseball’s Yogi Berra, “it’s d´ej`a vu all over again”.

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McArthur G Kari S (2013) Globe investigation: The Ford family’s history with drug dealing. The Globe and Mail, Published Saturday, May. 25 2013, 3:00 AM EDT, cited in http://www.theglobeandmail. com/news/toronto/globe-investigation-the-ford-families-history-withdrug-dealing/article12153014/?page=al l retrieved October 5, 2014 31 Rob Ford on drug use: ‘You name it, I pretty well covered it’: Toronto mayor tells CBC drug use began long before he became mayor. CBC News Posted: Jul 02, 2014 7:43 AM ET Last Updated: Jul 02, 2014 10:15 PM ET cited in http://www.cbc.ca/news/canada/toronto/robford-on-drug-use-you-name-it-i-pretty-well-covered-it-1.2693774 retrieved October 5, 2014 32 Isaacson W (2011) Steve Jobs. Little, Brown & Company. 33 Cannabis use in Canada: A presentation at the first Issues of Substance Abuse Conference in Markham, Ontario. AFM (Addictions Foundation of Manitoba), cited in http://en.wikipedia.org/wiki/ Adult lifetime cannabis use by country retrieved October 5, 2014 34 Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys. July 2008, Volume 5, Issue 7, e141. PLoS Medicine (Public Library of Science). Cited in http://www.plosmedicine.org/article/fetchObject. action?representation=PDF&uri=info:doi/10.1371/journal.pmed. 0050141 retrieved October 5, 2014 35 Timeline of cannabis legalization in the United States. http://en.wikipedia.org/wiki/Timeline of cannabis legalization in the United States#States retrieved October 6, 2014. 36 Frosch D (2014) “ ‘Lab Rat’ Ads Warn Teens Of Pot Use.” The Wall Street Journal. Monday October 6, 2014, Page A3 Columns 1–4.

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With the increasing normalization of marijuana and demonization of tobacco, and other shifts in how we consider certain substances, it may be time to give some thought to the positives of drug use, not only for the current drug user, but also for the general population. Drugs which are currently banned may be a source of new treatments. Marijuana may have a role in dealing with anorexia or as an anti-emetic in cancer patients. Tobacco is a mild stimulant and anorexiant37 . Opium is an antidiarrheal. Coca is a mild stimulant for those working in low oxygen environments. Cocaine is a local anesthetic for eye surgery, acts as a topical vasoconstrictor, normalizes gut function, relieves intra-ocular pressure associated with glaucoma, treats opioid dependence and improves symptoms of Crohn’s disease38 . Cocaine’s role as an “industrial strength” stimulant is dramatically illustrated in the movie Flight39 starring Denzel Washington as Whip Whitaker, a quasi-comatose alcoholic airline pilot who is force-fed sniffs of cocaine to wake up for work after a night of drunken debauchery. Those of us who cannot start to function each day without our morning cup of Java and who cannot sustain our productivity during the day without additional copious cups of coffee, tea, Coca-Cola, chocolate, and other products containing caffeine are using an analogous if less powerful wake-up remedy. The following substances may also have a role in providing new treatments37 . Small amounts of psilocybin (found in some mushrooms) can relieve the symptoms of cluster headaches, obsessive–compulsive disorder and depression, and enhance recall. One can only wonder or hope that this could be useful with age-related dementias. Ecstasy (MDMA) produces feelings of emotional warmth, high levels of energy and may be useful in treating posttraumatic stress disorder (PTSD); it also may have anticancer properties (leukemia, lymphoma, myeloma). The hallucinogen LSD may have potential for treating alcoholism. Ketamine may combat symptoms of depression. Finally, prescription psychoactive substances, such as tranquillizers, anxiolytics, analgesics, have a role not only in controlling pain and psychic malaise, but are often used as a means of coping with unsatisfactory personal or social situations over which the person has little control. A person may use these substances to be able to endure mental or physical spousal abuse where leaving is not an option (lack of education or marketable skills, small town, threat of loss of children). They may allow a person to be able to function in periods of extreme danger (during war, in the midst of exploding bombs). According to the popular tropes shown in American movies or TV, the best way for a person to deal with something that is painful is to face up to it and come to terms with it. However, this is not always possible due to lack of time for counseling or therapy when facing an urgent life-threatening situation. To 37 Which may partly account for the rise in smoking among girls and young women pursuing the current social ideal of a slim figure. 38 Lallanilla M (2013) 6 Party Drugs That May Have Health Benefits. Live Science. November 18, 2013 09:15am ET. http://www.livescience. com/41277-health-benefits-illegal-drugs.html Retrieved October 7, 2014 39 Zemeckis R. Flight (2012) Paramount.

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acknowledge the problem means acknowledging the existence of an intolerable situation that must nevertheless be tolerated lest the person die. In such cases denial aided by substances, legal or illegal, that deaden the senses may be the best option as it allows one to function and stay alive. There remain many barriers to being able to fully integrate the perspective of the addict—including further consideration of the beneficial effects of drugs and drug use—into our understanding of addiction. There is a considerable misunderstanding of the words “drugs,” “drug use,” “drug user,” and “addict”, as well as what is meant by “therapeutic interventions.” As Stan Einstein has pointed out, Consider that psychoactive substances, natural as well as man-made, have filled a range of individual, familial, community and other systemic network functions, since the first outcome of fermentation was discovered and tasted by wordless gatherers who institutionalized its use as they transformed themselves into hunters, growers, and, finally, as socializing secular and “believing” civilized settlers. Consider that the categories “soft” and “hard drugs” are misleading, unscientific categories of active pharmacological substances which have been and continue to be used by individual and systemic stakeholders for achieving a range of goals and objectives which include the legal and/or social status of selected “drugs” in which their pharmacological actions and/or the simplified albeit complex “drug experiences” are not critical criteria. Distinguish between pharmacological action, and one’s “drug experience,” which is the outcome of the complex interactions between the chemically active substance, the user and where it is being used-or site, in addiction research and intervention semantics40 . Consider that the differences between “illness”, which is experienced by the person, and “disease”, which is a diagnosed condition or state of an organism, live or dead, are associated with a range of different implications, consequences and challenges to formal caretakers and deliverers of services. There is no “magic bullet” addiction treatment, whatever its ideological underpinnings. The same treatment models and/or techniques are used with the range of substance users as are used with non-drug users in any given historical period, place and culture-social status of selected “drugs” in which their pharmacological actions and/or the simplified albeit complex “drug experiences” are not critical criteria The medicalization of human behavior, documented in the latest secular psychiatric Bible—the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V)41 —continues to expand, and this further distances the addict from those who would study and/or help him. 40

Zinberg NE (1984) Drug, Set, and Setting: The Basis for Controlled Intoxicant Use. New Haven: Yale University Press 41 American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-V), 5th Ed; Washington, DC: American Psychiatric Association.

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M. ADRIAN

Stan Einstein notes that there have been 53 theories as posited etiology of drug use, published by a government agency42 I would add that there are also many sociological theories of addiction43 , and many theories that are oriented to subpopulations only44 . To my knowledge, none has been able yet to account fully (or even mostly) for addiction, or to serve as the basis of consistently (or at least usually) successful intervention. Policies may be instituted due to political necessity that requires that vigorous, albeit untested, action be seen to be taken when a new and frightening problem arises, in order to prevent public panic and maintain social stability. Sometimes it is not clear if the action’s intent was to “cure” the substance users’ problems, however, this loaded term is defined and delineated, or to use the effects of the substances to control the population. According to Stan Einstein, although the 13-year (1920-1933) social “experiment” of Prohibition had failed to achieve and sustain its law-control agenda in the USA45 , American President Richard Nixon declared a “war on drugs” in June 1971. He legislated it in January, 1972, which dramatically increased the size and presence of federal drug control agencies, and pushed through measures such as mandatory sentencing and no-knock warrants. Russia’s “vodka politics”, from the time of Peter the Great to Stalin’s use of vodka as a control weapon, is increasingly being examined46 , as are the centuries of Western colonizers using psychotropic substances to enslave and exploit indigenous populations for God and King-Queen47 . Researchers, whose academic, financial and social conditions depend on publishing or perishing, in particular in the publishing of papers that report successful outcomes, are more likely to undertake activities that replicate, with small incremental changes, ideas in other scientists’ research. (viz, the rarely published materials exploring substance use intervention failures48 ). Consensualized failure may result in “failure blindness” with the consequences that may be expected from funding agencies. Totally, novel ideas are likely to be misunderstood by reviewers and become difficult to fund through the usual funding agencies. Hence the researcher will likely stick to what urban planners Horst Rittel and Melvin Webber49 42

Lettieri DJ et al (eds) (1980) Theories on Drug Abuse. NIDA Research Monograph No. 30, Rockville, MD: NIDA. 43 Adrian M (2003) How can sociological theory help our understanding of addictions? Substance Use and Misuse; 38(10):1385–1423. 44 Lightfoot L, Adrian M, Leigh G, Thompson J (1996) Substance Abuse Prevention A Review Of The Scientific Alternatives. in: Adrian M, Lundy C, Eliany M (eds.) (1996), Women’s Use of Alcohol, Tobacco and Other Drugs in Canada. Toronto: Addition Research Foundation, pp. 186–204. 45 Okrent D (2011) Last Call: The Rise and Fall of Prohibition. NY: Scribner. 46 Schrad ML (2014) Vodka Politics: Alcohol, Autocracy, and the Secret History of the Russian State. NY: Oxford University Press 47 Curto JC (2004) Enslaving Spirits: The Portuguese-Brazilian Alcohol Trade at Luanda and Its Hinterland, C. 1550–1830. Leiden: Brill Academic Publishers. 48 Einstein S (ed.) (2013) Special Issue on Substance Use(r) Intervention Failures. Substance Use and Misuse, 47:13–14. 49 Rittel H, Webber M (1973) Dilemmas in a General Theory of Planning. Policy Sciences, Vol. 4, pp 155—16.

called “tame problems” that are solved in a traditional linear analytic known and tried “water fall paradigm”: gather data, analyze data, formulate solution, implement solution. The more interesting and challenging problems (the “wicked problems”) that can only be responded to individually, each time anew, with no ultimate, repeatable solution are less attractive to the career scientist unless he or she works in an environment that can afford to allow staff, during their work day, to work on private projects that may, or may not, yield results. Physicist Albert Einstein wrote much of his seminal work during his normal work hours after he had finished his job-related duties at the Swiss patent office that day. 3M corporation allows an employee “to work independently on his own product idea”50 . Similar conditions exist at Google and other industries where discoveries may lead to products and/or processes that can be profitably commercialized. Despite all the difficulties stemming from dealing with a situation where the person who lives it is often perceived as someone who is devalued but whose perspectives and narratives nevertheless can improve our understanding of addiction, being aware of and considering the perspective of the “addict” may be difficult because of the different and sometimes opposite realities the word represents. Is the term “addict” used to denote a homogenized, marginalized, dehumanized, and stigmatized being, or can there be possible recognition that the term “addict” is used about an inspired, sensitive, brilliant, unique person who has special characteristics of their own beyond those of just “being an addict”? Taking the perspective of the addict may expand our view of the world and improve our understanding of “addiction”, whether considered as a concept, a process, a flawed political mantra and stakeholder agenda, or a deeply penetrating and insightful view of a nonmainstream reality whose contribution to forming our world is not yet fully realized, that may yet permit the making of better informed decisions. It may prepare us to better deal with future social or political developments that may completely reverse previous policies or ways of doing things. It may prepare us for the future, because the future exists today among us, among those whose voices are not being heard today, but whose whispers will form the world in which we will be living tomorrow with its ever-present, albeit denied, uncertainties and unpredictabilities, some of which may be unpleasant, and others which may be very pleasant indeed, or both. Perhaps at the same time. Declaration of Interest

The author declares no conflict of interest. The author alone is responsible for the content and writing of the paper.

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3M (2002)—A “Tolerance for Tinkerers.” A Century Of Innovation: The 3M Story. 3M Innovation. p 19. http://multimedia. 3m.com/mws/mediawebserver?6666660Zjcf6lVs6EVs666IMhCOrrrr Q- retrieved October 12, 2014.

WHAT WAS BAD IS NOW GOOD, AND WHAT WAS GOOD IS NOW BAD

THE AUTHOR Manuella Adrian, M.Sc.Hyg., researcher, writer, academician, manager. Her main research interests include addiction, substance use, and misuse (alcohol, drugs both legal and illegal, prescription psychoactive drugs, tobacco), population health, epidemiology, health economics, health care management and delivery, costs and cost-benefit analyses, special populations (women, youth, elderly, Natives), research methods (quantitative and qualitative),

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the construction of social, economic and health indicators, statistics and the visual display of information, public information and communication, and issues of governance and socio-cultural and physical environmental context. She has worked at the Addiction Research Foundation (ARF), Health and Welfare Canada, the Ministry of State for Science and Technology. She has taught at Florida International University, Nova Southeastern University. Her cross-appointments include, or have included, Guelph University, University of Kansas, Carleton University. She has been a consultant to the World Health Organization (WHO, Geneva), the Pan American Health Organization (PAHO, Washington D.C.), and the Organization for the Control of Endemic Diseases in Africa. She is a member of the editorial board of Substance Use and Misuse.

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